Our lifestyle has changed much during the last few decades. In the changed scenario the biggest users of health care system are the elderly people. A 65 year old male patient reported to King Khalid University-dental clinics, complaining of inability to masticate, unaesthetic facial appearance and psychological stress. He had multiple missing teeth, severely broken teeth and recurrent aphthous ulcers. Digital photographs displayed on a large monitor helped us to explain to him the dental problems, solutions and their possible consequences. The rehabilitation process started by relief of presenting symptoms, extraction of teeth with hopeless prognosis, periodontal treatment, excavation of carious teeth, root canal treatment for the indicated teeth and restoration of all coronal portion of the remaining teeth. Fixed partial dentures were constructed in the maxillary arch first. The mandibular arch was restored by a combination of fixed partial dentures with extra-coronal attachments joined with removable partial denture following a mandibular transitional denture. Review after 3 and 6 months revealed a marked improvement in the patients' over all condition.

World demographic changes show an increase in the elderly population worldwide. Due to increase in life span, the continuously growing elderly populations require extra health care attention. [1] This has a great effect on dental practice too. Geriatric patients can have general health problems that are age dependent and specific dental problems. These problems require special skills on the part of the dentist to deal with aging dentitions. [2] One of the common dental problems of geriatric patients is missing teeth. Teeth loss, especially in the anterior region has negative effect on the social life of an individual which consequently affects his psychological makeup. Being edentulous is a handicap, partially edentulous patients with multiple teeth loss are considered having a kind of disability that are eligible for full prosthodontic rehabilitation. [3] The abutment system offers the choice of both removable and fixed prostheses with identical secondary parts. Clinical presentation and various types of fixed or removable prostheses alternatives and variations of design pose challenge in deciding a treatment plan. Prosthetic design depends on the number and location of abutments. [4] Prosthetic treatment in oral rehabilitation is known to improve subjective perception of facial aesthetic, psychological status and of the social relations of patients with partial edentulism. [5]

Recurrent aphthous stomatitis (RAS) is a common and painful oral mucosal disease. Possible etiologies include genetics, vitamin deficiencies, trauma, immune dysfunction, and closely related to stressful status of the patient. [6] In patients with a history of RAS, stressful events may mediate changes involved in the initiation of new RAS episodes. Mental stressors are more strongly associated with RAS episodes than physical stressors. [7] The aim of this report is to present a case of complete oral rehabilitation of 65 year old male patient suffering from multiple teeth loss and RAS leading to stress and swings in mood.

Case Report

A 65 year old male patient reported to dental clinics - college of dentistry at King Khalid University, complaining of inability to masticate, and unaesthetic facial appearance. He also complained of jaw pain and headaches. After taking patient's consent, routine medical and dental screening with intra oral, extra oral examination, intra oral charting [Figure 1] and interpretation of full mouth radiograph was done in the 'oral diagnosis clinics [Figure 2] a-c. Apart from missing and decayed teeth intraoral examination revealed remaining roots and mucosal ulcers [Figure 3]. Aphthous ulcers of about 5-8 mm in size were seen on the labial and buccal mucosa. These were diagnosed as minor RAS also known as Miculiz's aphthae according Natah et al., [8] criteria. Maxillary and mandibular primary impressions were taken for preparing study casts. A team of oral diagnostician, endodontist, periodontist and prosthodontist discussed the findings and decided to treat the patient in 'advanced clinical dentistry' clinics. To restore the function and aesthetics of the oral cavity different treatment modalities ranging from conventional removable partial dentures (RPD) to implants were discussed with the patient. After a thorough discussion of treatment options, the patient chose to address all of the issues with full-mouth rehabilitation.

The rehabilitation process started in the 'diagnosis clinic' with the prescription of topical and oral analgesic/anti-inflammatory agents for the relief of presenting symptoms of RAS, [9] and headache. The extraction of remaining roots with hopeless prognosis was done under local anesthesia (21 and 28). In consultation with the oral diagnostician and endodontist, teeth that required restorations, root canal treatment (RCT) and post and core placement were identified. This followed excavation and restoration of carious teeth (12, 17, 22, 23 and 27) and full mouth scaling. During this phase oral hygiene instructions were also given.

The next step in the corrective phase was prosthetic treatment. This was initiated with the fabrication of three separate fixed partial dentures (FPD) in the maxillary arch. In the maxillary right quadrant, teeth numbers 13 and 16 formed the abutments for pontics in place of 14 and 15. In the maxillary left quadrant 23 and 26 were used as abutments for pontics in place of 24 and 25. The third bridge spanned between 11 (abutment) and 22 (abutment), with 21 as the lone pontic. All the FPD in this case were made of nickel chromium casting alloy (Wiron 99, Bego, Germany) and feldspathic porcelain (VITA Vmk 68, Germany) [Figure 6]a and b. Simultaneously, posterior mandibular transitional denture was fabricated to re-establish the lost vertical dimension in the posterior region.

The prosthesis design for the mandibular arch consisted of a long anterio-posterior bridge and a cast partial denture. Teeth number 31, 32, 35, 41, 42 and 45 formed abutments of the long anterio-posterior bridge. The remaining teeth between the abutments (33, 34, 43 and 44) formed the pontics. This bridge had a female part of the extra coronal attachment on the occlusal surface of the posterior most abutments [Figure 7]a-d. The male part of the attachment was part of the cast partial denture which was fabricated to replace the transitional denture delivered in the previous step. The cast partial denture was designed having bilateral lingual clasps and a lingual bar joining both the posterior extensions for the free end saddle. It replaced the missing mandibular molars bilaterally (36, 37, 46 and 47). The cast RPD was made from cobalt-chromium alloy (Biocast, Rx Generic Corp, Wallingford, CT, USA). The fixed and removable prosthesis for maxillary and mandibular arches were constructed using face bow and mounted in semi adjustable Hanau TM articulator (Waterpik ® Technologies, Fort Collins). The prosthesis were cemented with resin cement (Relaxy XTM, Unicem AppliCap Resin Cement, 3M ESPE, Germany) following the manufacturer's instructions [Figure 8].

The case was followed up and recalled after 3 and 6 months for maintenance phase [Figure 9]a-c. In these follow up visits a marked improvement in the mastication, facial appearance, speech, social life, and psychological status with disappearance of RAS episodes was noted.

This case report illustrates the management of a geriatric patient with extreme multiples consequences of partial edentulism. The sequence of treatment steps were closely followed with that of established steps for treating partial edentulism. [10],[11] The maxillary arch was restored with FPD prior to the mandibular arch to establish the occlusion plane. The mandibular arch received an anterior bridge with male part of attachment followed by poster cast RPD with female part.

Partial edentulism has multiple implications in relation to function, esthetics and full mouth rehabilitation. The aim of prosthetic rehabilitation in geriatric patients is mainly to restore masticatory function, appearance and muscle function. It helps to maintain and improve phonetics, prevent development of deleterious oral habits and to minimize possible psychological disturbances. Each year millions of elderly persons suffer as a result of maltreatment. [12] As the number of geriatric patients increases the number of maltreatment cases is expected to rise. [13] Therefore, partial edentulism in geriatric patient's pose a unique challenge requiring a multidisciplinary approach for treatment. Increase in age of partially edentulous patients cannot be directly related to the survival of prostheses. Although many studies did not show any effect of age on the survival of fixed prostheses, there is evidence that middle-aged patients may present with higher failure rates. [14] Prosthodontic therapy for this unique patient group is challenging and neglected due to the limited number of abutments, loss of vertical dimension and poor occlusion. [15] Two year follow up of a patient rehabilitated by a combination of fixed and removable dentures showed improvement in quality of life due to the prosthesis. [16] Petricevic et al., [17] reported that FPD and implant-supported FPD treatment showed significant improvement of oral health-related quality-of-life. Gârbea et al., [18] concluded that prosthetic rehabilitation with partially edentulous patient is immensely successful in improving psychological, speech and swallowing problems in such patient.

Observations from the aforementioned studies coincide with the result of the oral rehabilitation case presented in this report. The improved well being of the patient was evident by a marked increase in his body weight within three weeks from the commencement of the rehabilitation process. This was also reflected by total disappearance of RAS episodes. The masticator performance appeared to be enhanced as result of proper occlusal contacts resulting in proper distribution of occlusal forces.

Conclusion

The management of the presented case reflects the importance of judicious use of prosthodontic principles and strategic planning in addition to multidisciplinary team work when treating geriatric patients. Despite the significant disfigurement of the occlusal plane before the start of the treatment, optimal and esthetically pleasant occlusion was achievable by restoring the lost vertical dimension. Provisional prostheses enhanced the predictability and patient adaptation to the definitive prostheses. Increased age of patients should not be considered as a risk factor for oral rehabilitation. The Oral rehabilitation is a complex task, and more information regarding treatment protocols, prosthetic indications and treatment outcome is needed.